Get Ny Callen Lorde Health Information Release Form 2019-2025

Filling out the NY Callen Lorde Health Information Release Form online is an essential process for authorizing the sharing of your health information with designated individuals or organizations. This guide provides step-by-step instructions to help you complete the form clearly and accurately.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to obtain the NY Callen Lorde Health Information Release Form and open it in your preferred online editing platform.
2. Begin by filling out Section 1, which includes your personal information. This section requires your last name, first name, today's date, address, apartment number (if applicable), city, state, date of birth, phone number, and zip code.
3. In Section 2, provide the details of the individual or organization to whom you are authorizing the release of information. Include their name, the organization and department, address, city, state, zip code, phone number, and fax number.
4. Move to Section 3 to select how you want your information disclosed. You can choose from fax, mail, or pick-up options. Additionally, specify which medical and dental records are to be released by checking ‘Yes’ or ‘No’ for each type requested.
5. For sensitive information, go to Section 4. Sign next to any categories of sensitive information you authorize to be released, including HIV-related information, mental health treatment, and substance use treatment.
6. In Section 5, indicate the reason for the information release and specify an expiration date if it differs from 12 months.
7. Finally, review your completion of the form. Once all sections are filled out accurately, you can save changes, download, print, or share the form as needed.

Start completing your NY Callen Lorde Health Information Release Form online today!